Clinicians have a variety of well-tested ways of identifying those individuals who are at highest risk for suicide, but they have no such well-tested methods for determining when a particular individual is most likely to attempt suicide. This is a serious shortcoming because the “when” is a particularly important issue: If clinicians could predict when a suicide attempt is likely to occur, they could intervene and help the at-risk individuals get through their crisis periods safely.

Over time suicide specialists have identified a number of warning signs that are thought to predict periods of near-term risk (i.e., clinically relevant time periods of risk entailing hours to a few days) for individuals who are already known to be at high risk of suicide; indeed, the VA and Department of Defense provide clinicians with lists of such warning signs. However, a recent review by an expert panel from the American Association of Suicidology found that there is actually very little scientific evidence to support the use of these warning signs. While suicide researchers have carried out some controlled validity studies on civilians, there have been no controlled studies on near-term risk for suicidal behavior among military populations.

Thus Courtney Bagge of the University of Mississippi Medical Center in Jackson and Kenneth Conner of the University of Rochester Medical Center and the VISN 2 Center of Excellence for Suicide Prevention are carrying out a large-scale study to address this shortcoming. “As clinicians, if someone is leaving our office, we want to know if he or she is at increased near-term risk for attempting suicide. Thus, we are particularly concerned with the next 24 to 48 hours,” Bagge says. “This research is about ‘Why today? Why did someone choose to attempt suicide today, compared to a previous day which was close in proximity?”

To look for reliable warning signs of impending suicide attempts, Bagge and Conner will be studying 250 Veterans at three VA locations—in Little Rock, Arkansas; Puget Sound, Washington; and San Diego, California—as well as 250 civilians at the University of Mississippi Medical Center and the University of Rochester Medical Center. In particular, they will be studying Veterans and civilians who have recently attempted suicide.

Patients who come to one of the study facilities because of a recent suicide attempt (within the previous 48 hours) will be interviewed using a cued timeline follow-back methodology (the Timeline Follow-Back for Suicide Attempts Interview) to determine what they were doing and what they were thinking and feeling in the 48 hours preceding the suicide attempt. After gaining basic information to serve as anchors for recall (e.g., location, activities), the researchers will gather information on the timing of behavioral warning signs during the 24 hours before the suicide attempt as well as the 24-hour period before that. For intensity of thoughts and feelings, the interview will focus on the 6 hours before the suicide attempt and the same 6-hour period on the day before. By looking for differences between what the people were doing, thinking, and feeling in the period immediately before the suicide attempt and on the previous day, Bagge and Conner hope to be able to identify warning signs that indicate when a suicide attempt is imminent. In particular, they will be examining a lengthy list of potential warning signs to see which of them can effectively distinguish between the two time periods, one in which a suicide attempt did not take place and one in which it did.

Preliminary studies have already shown strong empirical evidence for two warning signs listed by the expert panel, Bagge said. When a person who is already at a high risk for suicide drinks excessively, it uniquely increases the risk of a suicide attempt within the next 6 hours by a factor of six or more, and the highest alcohol-related risk for suicide attempt occurs within an hour of the last drink consumed. Similarly, suicide attempters are five times more likely to experience a negative romantic interpersonal life event—such as a fight with a loved one—on the day of their attempt compared to the day prior. Although these are only preliminary results, they give Bagge hope that the more intensive study will find a number of reliable warning signs for suicide attempts.

Bagge said that she and Conner will be examining such questions as whether the warning signs for suicide are different for Veterans and civilians and whether a short list of warning signs—perhaps no more than four—or a specific combination of warning signs can be as effective as the much longer list in identifying those at high risk for suicide attempt within 24 hours. They will also be testing a simple paper-and-pencil questionnaire to determine if it can pinpoint warning signs as well as the much more time-consuming personal interviews.

Once the researchers have produced an empirically validated set of warning signs, there are a number of ways this knowledge can be put to work, Bagge said. Clinicians can be educated about exactly which warning signs have empirical evidence. Patients and their families and friends can be educated about what to do if the patients have certain experiences or start to feel certain things. Knowing the warning signs can also help clinicians with planning for patients after discharge; by knowing the sorts of things that precede a suicide attempt, it may be possible to do various things to reduce the risk of another attempt. Finally, Bagge said, she hopes that knowledge about the warning signs of a suicide attempt will help inform research on suicide prevention and intervention so that researchers can develop more effective ways to make suicide attempts less likely.